Global Advancement in Pharmacy Services for Mental Health: A Review for Evidence-Based Practices

The symptoms of psychiatric infirmities have variability, and selected drug regimens for mental illness are comparatively complex and individualized; therefore, pharmacy services vary with respect to patients, diseases, healthcare settings, community structures, and countries. Clinical pharmacy services for mental health (MH) are continuously being upgraded. A structured search of the literature was performed in the Cochrane, PubMed (Medline), PsycINFO, Google scholar, Scopus, Science Direct, and Springer Links databases. The title and abstract of each retrieved article were evaluated for relevance. To remove uncertainty and ambiguity, the full-text articles were retrieved and examined for relevance. The articles were further assessed on the basis of inclusion and exclusion criteria. Narrative synthesis was performed, creating new categories and relevant subcategories and further subsections. The articles and the results were assessed for quality and bias. Pharmacists have a range of expertise in psychiatric care. The services can be classified as conventional, extended, and advanced pharmacy services. Conventional services include the quality use of medicines in healthcare settings and medication support services in communities that ensure medication adherence. Pharmacists perform extended roles in collaborative medication therapy management, multidisciplinary community mental health teams, collaborative care, patient education, home medication review, hospital-to-home transit, and screening services. In the USA, the role of pharmacists was advanced by prescribing as collaborative and interim prescribers. Australia launched an accredited program for psychiatric first-aid pharmacists. Pharmacists can provide mental care to rural populations using health technology. The role of pharmacists in MH is appreciated either independently or as a team member. Patients and healthcare providers rank the services of pharmacists in MH highly. Still, there is a margin for improvement in the training of pharmacists. Pharmacists cannot provide sufficient time to their patients. Public awareness about the role of pharmacists in MH needs more attention. Moreover, the training of psychiatric pharmacists should be standardized around the world.

hospital pharmacy services in MH, psychiatric issues solved by pharmacist, and PC for intellectual disability.

Article Selection and Data Collection
The title and abstract of each retrieved article were assessed for relevance. In the case of any ambiguity or uncertainty, the complete article was investigated for relevance. The articles were further assessed according to inclusion and exclusion criteria, as given in Table 1. News reports, editorials, blogs, commentaries, opinions, correspondence, research protocols, articles in non-peer-reviewed journals, articles in nonindexed journals, and minireviews.

Duration
Publications from 1990 to present.

Publication classification
Full-text research articles in peer-reviewed scientific journals. 3 Language selection All articles published in English. 4 Healthcare setting Community, geriatric, hospital, and residential pharmacy services.

Methodology
Original articles in peer-reviewed journal investigating/comparing pharmacy services in MH.
The selected articles that explored pharmacy services but did not focus on MH were separated for this study. For the identification of the main services that were depicted in the literature, each article was fully studied. However, a manual search was also performed to retrieve more articles that were cited in different articles but were not found using the search strategy.

Study Selection
The studies identified through the literature search were screened by two independent reviewers to assess their eligibility. Any disagreements were resolved through consensus or by a third reviewer. After evaluating all the databases, the studies were screened for duplications, which were then deleted. The articles were also excluded after screening the titles and abstracts.

Data Extraction
Data were extracted from the eligible studies using a standardized data extraction form. The data included information on study references, designs, research objectives, and outcome measures.

Quality Assessment
The Mixed Methods Appraisal Tool (MMAT) was used to appraise the quality of the empirical studies, as it covers a variety of methodologies. The MMAT includes five core quality criteria for each of the five following categories of study designs: qualitative research, randomized controlled trials, nonrandomized studies, quantitative descriptive studies, and mixed-method studies. Critical appraisals of the methodological quality and the risk of bias assessment of the included papers were undertaken independently by two re-viewers (RSA and BEA). A third reviewer (MA) was consulted in cases of disagreement without reaching consensus.

Analysis
A narrative synthesis approach was used to synthesize the findings of the included articles due to the heterogeneity of the studies in the review, with a range of methodologies. First, a preliminary synthesis was conducted to search the studies and present results in a tabular form. Then, the results were discussed by two reviewers (RSA and RAA) and structured into themes. The studies included in the narrative synthesis were then summarized within a framework.

Literature Retrieval
In total, 48,744 articles were recognized by the search of the databases. Then, 48,604 articles were removed on the basis of ambiguity and duplication. On the basis of the inclusion and exclusion criteria, 86 articles were removed. Thus, 68 articles were included in this review ( Figure 1). the risk of bias assessment of the included papers were undertaken independ reviewers (RSA and BEA). A third reviewer (MA) was consulted in cases of d without reaching consensus.

Analysis
A narrative synthesis approach was used to synthesize the findings of articles due to the heterogeneity of the studies in the review, with a range of gies. First, a preliminary synthesis was conducted to search the studies and pr in a tabular form. Then, the results were discussed by two reviewers (RSA an structured into themes. The studies included in the narrative synthesis were t rized within a framework.

Literature Retrieval
In total, 48,744 articles were recognized by the search of the databases. articles were removed on the basis of ambiguity and duplication. On the ba clusion and exclusion criteria, 86 articles were removed. Thus, 68 articles w in this review ( Figure 1).   The 68 articles in this review include 6 retrospective studies, 22 RCTs, 1 simulated  patient, 5 qualitative studies, 6 mixed-method studies, 12 descriptive studies, 2 observational studies, 4 prospective studies, 5 cross-sectional studies, 2 controlled studies, and 1 uncontrolled feasibility study.

Risk of Bias and Quality Assessment
All the included articles met the screening criteria: having clear research questions and addressing the research questions based on the collected data. Almost all articles were rated as average or above-average quality (see Supplementary Materials).

Pharmacy Services
According to the nature of pharmacists' roles in MH, pharmacy services were divided into three types, i.e., conventional, extended, and advanced pharmacy services.

Conventional Services
Pharmacists traditionally perform duties in different segments of MH, i.e., the quality use of medicines in healthcare settings, medication support services in communities, and medication adherence ( Table 2).   Information about the risks and benefits of antidepressants was provided by pharmacists.

Extended Services
Commonly performed extended services include residential medication management reviews(RMMRs) and home medicine reviews(HRMs) in Australia, medicine use review services (MURs)in the UK, medication therapy management (MTM) in the US, and medication review services (MRS) in New Zealand [20] (Table 3).
The integration of pharmacists improves the prescription of psychotropic drugs.

Advanced Services
Pharmacists are becoming more and more engaged in MH, and their role is advancing. The nature of the advancement varies from country to country (Table 4).  Specialist teams could quickly resolve medication problems. Leads to bridging between secondary and primary care.

Healthcare Provider Satisfaction
Two studies from Australia elaborated the role of psychiatric-specialist pharmacist (PSPs). There was a great recognition and acceptance by other HCPs for their role in the Healthcare 2023, 11, 1082 13 of 21 management of psychiatric patients. PSPs addressed an unmet need for pharmaceutical services. The medication expertise of PSPs was highly regarded [40,62]. A recent study from Qatar revealed high expectations of doctors and nurses for the tasks of pharmacists at a mental care hospital. They had positive perceptions about the clinical role of pharmacists. On the other hand, conventional clinical services performed by pharmacists were more favorably analyzed than advanced clinical responsibilities such as prescribing and medication management [63].

Patient Satisfaction
Black and his colleagues reported that victims of mental issues noticed the significance of pharmacy services. Conventional pharmacy services such as medicine information were considered more essential than clinical services. This study also found that the significance of a pharmacy service was always associated with its provision [64].
Two studies from Australia viewed the customers of pharmacies in community settings. The confidence levels of patients were assessed. The services were highly valued by participants, and they considered the community pharmacies to be safe places to obtain advice on MH and wellbeing. The studies showed good conjecture regarding the role of pharmacists [65,66]. However, the rural population of Australia wished to find expanded services for MH similar to the urban population [67]. In the US, schizophrenic patients viewed pharmacists as knowledgeable sources, but their perception of pharmacists was primarily as dispensers of medicines [68].

Challenges and Limitations
Only two challenges were found in the literature, i.e., related to practice and pharmacist training.

Challenges of Practice
A lack of time with pharmacists, low awareness in the public about the role of pharmacists, and the low knowledge of customers about provided help and available resources are major challenges, especially for the depression screening services at community pharmacies [69]. The literature indicates challenges in the implementation of an accredited first-aid program [70]. Challenges regarding training in first aid were also reported [71]. In addition, some challenges such as a lack support from the owner, manager, or staff of a pharmacy; privacy limitations; and time constraints were reported from community pharmacies for the provision of medication management in MH [39]. Key challenges identified in patient care in the hospital-to-home transition included limited knowledge and insufficient communication. It was also reported that there is a need for a standardized role [53].

Inappropriate Training of Pharmacists
Suboptimal attitudes towards disease conditions and a lack of self-reliance in the provision of clinical services to patients necessitate special didactic approaches. It was also identified that educational programs should shift from the conventional focus of therapeutics such as antipsychotic remedies. The adaptation of evidence-based medication and practices will decrease the stigma of MH. It was also noticed that an improvement in the professional confidence of pharmacists is needed to offer suitable MH services. The training of pharmacists must have a focus on the development of communication skills [72,73]. A recent survey in the US reported the views of pharmacists about their training, and they claimed that the emphasis on MH in their training was not adequate [74].

Discussion
Medicines remain a key modality for the treatment of numerous psychological issues such as bipolar disorder, depression, and schizophrenia. Therefore, it is logical that pharmacists are supposed to contribute to the management of mental diseases via the quality use of medicines. The literature highlights this imperative clinical task of pharmacists in hospital and community settings [75,76].

Quality Use of Medicines in Healthcare Settings
A study from Canada and three other studies from the USA also showed the potential of community pharmacies to encounter the misuse of illicit drugs for psychiatric issues. It was also found that the proper care of patients can eradicate addiction [13][14][15][16]. However, a study of an Australian community pharmacy showed the medication-centered approach for antidepressant use. However, this study lacked patient-centered communications. The behavioral and psychosocial discussions, particularly those related to lifestyle modification, were missed. Emotional empathy building and facilitating the involvement of patients were also overlooked [17].
Some previous analyses stated that patient counseling by pharmacists and the monitoring of therapy can optimize medication and improve adherence in hospital and community pharmacy settings [75,76].

Medication Support Service in Community
An exploration in a primary care setting in Australia revealed the decision making via a deep discussion between community pharmacists and physicians to cure mental disorders. A detailed conversation about issues associated with potential and actual medication was carried out. The approaches that optimize individual medication regimens were the focus. Face-to-face conference meetings were conducted for 44 cases.
The doctors assumed their final decision-making task, but it was predicted by them that pharmacists are capable of medication adherence improvement. The physicians also acknowledged that a number of patients were more interested in information sharing with pharmacists than doctors [18].
Similarly, another qualitative study from Australia showed that pharmacy staff are ideally positioned to implement a medication support service [19].

Medication Adherence
Nonadherence to psychotropic therapy remains a common issue. Among them, nonadherence to antidepressant therapy was high. Treatment adherence prevents the recurrence of depression and decreases the healthcare costs [77]. Many studies have evaluated the success of complex and multifaceted interventions that improve adherence to antidepressants. These interventions included the strategies of patient education, telephonic follow-up to assess the patients' progress, and the feedback of a health team [78].
The engagement of pharmacists in medicine dispensing is historically understood. They are ideally positioned to support patient therapy and collaboration with patients. A pharmacist can easily evaluate and promote the importance of adherence to therapy. Previously, many studies were conducted in Australia, Brazil, Spain, the USA, the Netherlands, Saudi Arabia, and Kuwait with pharmacists involved in the management of depressive patients; however, the conclusions from these studies varied but showed measurable differences [22][23][24][25][26][27][28][29][30]. In contrast to these findings, the analysis by Brown et al. did not show proof of a difference between the usual and pharmacy-based management of depression in adults for symptomatic relief [78].
One study from the USA evaluated a pharmacy-based intervention for patients with serious mental disorders such as bipolar disorder, schizophrenia, and schizoaffective disorder. It showed an improvement in adherence to antipsychotic medication [33]. Although the facts point out the significance of pharmacists in improving psychotropic medicine adherence, these practices are not frequently used. A simulated client study from Aus-tralia indicated that the counseling of community pharmacists for antidepressants is not outstanding [34].

Collaborative Medication Therapy Management
A model of joint care known as collaborative drug therapy management (CDTM) is actually an accord between a pharmacist and physicians. In this type of effort, a pharmacist assumes responsibility for complete patient assessments, the selection and adjustment of drug regimens, and the monitoring and follow-up of patients for drug therapy. A descriptive study demonstrated the protocols for out-patient clinical pharmacy services by engaging a board-certified psychiatric in-community treatment center for substance abuse disorders and MH problems. This study also found certain obstacles in the USA, including prescriber-pharmacist relations, a lack of state and federal laws, the development of pharmacy informatics, and pharmacy services billing [35]. The high recognition of pharmacist advice in the US reveals the integration of pharmacists in CDTM. Integrating CDTM with a patient-centered medical home is an estimable patient-centered approach that addresses the therapeutic issues of homeless people [36]. Similarly, another study showed the development of a pharmacist-psychiatrist CDTM clinic [37]. Moreover, the pharmacy residency of a homeless-patient-aligned care team improved psychiatric pharmacotherapy follow-up, and interventions were found to be very effective [38]. On the other hand, a mixed-methods study of community pharmacies in Australia revealed some opportunities and challenges in the execution of an intervention that related to the therapeutic management of MH [39].

Multidisciplinary Community Mental Health Teams
After a long debate over many years, only a few studies assessed the integrated work of pharmacists in teams of professionals. The study from Australia by Bell et al. showed the incorporation of pharmacists as members of a community MH team, where five pharmacists were included for one day per week (for a 6-month duration). Their offerings were welcomed and valued by the team. The perspective of MH professionals and pharmacists is that the inclusion of pharmacists in community MH teams (CMHTs) addresses a dire need for pharmacy services among customers and staff. However, participation for only a single day per week seems trivial and hinders the impactful collaboration between the pharmacists and the CMHT members. However, this study answered the key question of whether a pharmacist should be considered an essential member of an interdisciplinary MH team [40].
Another study in the US by Mathys et al. investigated the inclusion of pharmacy students in multidisciplinary MH teams. The results showed no considerable differences between the control and experimental groups. However, the measures indicated comparatively high rates of patient counseling, interventions, and medication reconciliation [41].
A randomized control trial (RCT) in Flanders, Belgium was conducted by Liekens and colleagues. This RCT evaluated the impact of a pharmacist's training regarding the counseling of patients that initiate antidepressant therapy. It was concluded that special training on controlling depression improved the quality of the interactions between pharmacists and patients. This study also portrayed an improvement in lifestyle. It also revealed that pharmacists addressed psychosocial issues using PC [42].
A study from the US also described an interprofessional collaboration at an attention deficit hyperactivity disorder (ADHD) clinic for adult care. The execution of a collaborative service at the ADHD clinic demonstrated a successful coalition for MH [43].
Wang et al. conducted a study in the US that verified the role of pharmacists in CMHTs. They assessed the impacts of services provided by a psychiatric pharmacist in the health center. The community had limited access to psychiatrists. The study showed that the psychiatric pharmacist contributed to various areas of care such as psychotherapy and specialty care [44].

Collaborative Care and Patient Education
The partnership of healthcare providers and pharmacists has shown an affirmative role in juridical settings. A study from a prison in France showed that monthly meetings among pharmacists and psychiatrists about the execution of guidelines regarding benzodiazepine use led to significant decreases in the benzodiazepine doses per day [45].
A study from Sweden by Schmidt et al. showed that monthly multidisciplinary meetings by pharmacists decreased the use of antipsychotics, non-recommended antidepressants, and non-recommended hypnotics [46]. Bower and colleagues found an improvement in medication adherence associated with antidepressant use due to collaborative care strategies in primary care settings (OR = 1.92, 95% CI = 1.54-2.39) [64]. Two other studies from primary care settings in the US also found effective collaborative roles of psychiatric pharmacists [48,49].
A recent study from the Department of Veterans Affairs (VA) of the US showed the successful integration in practice and suggested that foundational concepts for the integration of pharmacists into interprofessional care teams can be applied in non-VA settings. MH clinical pharmacy specialists can work as direct patient care providers. Their services also improve clinical outcomes, access to care, and safety [50].
A study from India in a tertiary care setting for schizophrenia also showed that collaborative patient education by pharmacists and psychiatrists improved medication adherence and QOL [51].

Home Medication Review and Hospital-to-Home Transit
A study from the US concluded that pharmacists' contributions in care coordination promote adherence. They also manage serious mental illness [53]. Home medication review and hospital-to-home transit are two important aspects of PC in the community. Nishtala et al. found the significance of educational interventions and medicine use reviews for psychotropics in residential geriatric care communities. The hypnotic use was considerably decreased by medicine use reviews, as proven by a pooled odds ratio of 0.57 (95% CI: 0.4-0.7) [52].
Two Australian studies used the drug burden index (DBI) to determine the outcomes of RMMRs and HRMs that were conducted by pharmacists. These studies aimed to examine the total sedative medicine and anticholinergic burdens of people. Hence, these studies demonstrated significant reductions in the exposure to sedative and anticholinergic medicines of residents [54,55].
Nishtala and colleagues conducted a retrospective study of the DBI. A study of 500 HRMs in 62 geriatric care centers confirmed that HRMs conducted by pharmacists led to reductions in median post-RMMR scores (from 0.5 to 0.3) [54]. Similarly, another retrospective study was conducted in an Australian community. In this study, 372 HMRs were conducted by 155 pharmacists, and the mean DBI score was significantly reduced (from 0.5 to 0.2) [55]. A recent cross-sectional national Irish study of a pharmacy claims database also showed similar results in elderly people [56].
In Australia, Gisev and colleagues used a panel of experts to evaluate medication reviews that were independently conducted by pharmacists. This study showed that the recommendations and findings of pharmacists were appropriate [65].

Screening Services
Pharmacists are easily accessible in community settings, and no prior appointment is needed to screen for depression. They are considered trustworthy by the general public [20]. Earlier studies demonstrated that well-trained and competent pharmacists are equipped with the knowledge and skills to help the general public identify the early symptoms of depression, and they can support their customers during treatment [18,[66][67][68]72].
However, the screening of depression in a community pharmacy setting is not a common practice. Some pilot studies for feasibility showed that community pharmacists have the capability of early diagnosis. They are well positioned as a referral service for people at risk of depression [69,[79][80][81].
A study from the US also showed that pharmacists are ideal resources for monitoring patients that have a risk of suicide [82]. A recent qualitative study from the US also showed that patients and prescribers think that community pharmacists have the ability to screen patients for depression [83].

Collaborative Prescribing
An Australian study of secondary care investigated the attitudes of HCPs and customers about pharmacists' role as "collaborative prescribers" in MH. Both HCPs and customers recognized the role of pharmacists and PC in MH [84].
Joint efforts between doctors and pharmacists in the field of MH were evaluated in an Australian study of a primary care center. A total of 44 cases were scrutinized, and strategies were briefly discussed. In these cases, the optimization of therapy and treatment strategies as well as the exchange of patient and medical information were carried out. No biases or conflicts were reported [19].

Accredited First-Aid Provider
In 2001, Australia recognized the role of community pharmacists in MH as first-aid providers and set some standards for accreditations. Some basic training was necessary to meet the eligibility [20,71]. After that, it became an admirable training program in many other developed countries and the US. MH first aid is provided to a patient who is suffering from an MH problem or an MH crisis until proper professional help is provided or the crisis is resolved [73,85].
In 2018, Chawdhary et al. found that some challenges are associated with its proper implementation [70]. However, a recent study from the US indicated that patients are comfortable discussing mental issues with trained MH first aid providers. This revealed an opportunity for pharmacists to advance their services for MH [74,86].

Interim Prescribers
Turnover in psychiatric emergency services leads to fluctuations in the availability of prescribers. Patients face many problems due to the discontinuity of care. A retrospective cohort study was performed in the US with outpatients who lost their MH prescriber due to a transfer or turnover and needed medication therapy management (MTM). This study revealed a role of pharmacists as interim prescribers. Moreover, a reduction in the patient flow in psychiatric emergency was found [75].

Clinical Telehealth
Patients from rural areas have difficulties traveling and cannot seek proper MTM. Therefore, a recent study in the US evaluated the functions of a pharmacy MH clinical video telehealth (MHCVT) clinic. The patients showed great satisfaction with these MHCVT clinics. The visits to the clinics resulted in cost savings [76].

Solo PC and Health-Related Quality of Life
PC is assumed to be a direct intervention between the patients, HCPs, and pharmacists. PC optimizes therapy and reduces pessimistic outcomes related to medications. It also contributes to an improvement in health-related quality of life (HRQOL). A study from Colombia explored the execution of a PC program on the HRQOL of epileptic women. The results showed that the application of the PC program notably improved HRQOL [77].
Another study on long-term hospitalized patients with schizophrenia from Serbia also found that PC is a tool that improves the practices of medicine prescription in LMICs, regardless of a physician-pharmacist collaboration [78].

Specialist Mental Health Pharmacy Teams
The medication management of serious patients with mental chaos, such as schizophrenia or bipolar disorder, is not easy. A study from the UK showed the role of a specialist MH clinical pharmacy team that contributed to dose adjustment or polypharmacy and the monitoring of physical conditions and drug adherence. The staff of the surgical ward referred issues to the pharmacists for review.
The specialist MH clinical pharmacy team resolved the queries of the surgical staff about psychotropic medication. This team quickly resolved issues of drug errors and reconciled medication [87].

Conclusions
Pharmacists are providing many services in MH. Early screening and interim prescribing services will be beneficial and need universality. The training of psychiatric pharmacists in LMICs and developed countries should be standardized.

Supplementary Materials:
The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/healthcare11081082/s1. Table S1: Quality appraisal of the articles included in the review (R1); Table S2: Quality appraisal of the articles included in the review (R2).